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Scandinavian Journal of Pain 4 (2013) 153154

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Scandinavian Journal of Pain

journal homepage: www.ScandinavianJournalPain.com

Editorial comment

Even a simple pain condition such as Tennis Elbow is not only a somatic experience: body and mind are inseparable entities
Magnus Peterson a, , Harald Breivik b,c

Department of Public Health and Caring Sciences, Section of Family Medicine and Preventive Medicine, Uppsala University, Sweden University of Oslo, Norway c Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway

In this issue of the Scandinavian Journal of Pain, Garnevall et al. [1] report on psychosocial issues of lateral epicondylalgia (tennis elbow) and how current classications need revision so that these issues can be taken into account. Lateral epicondylalgia (LE) is a common condition with an incidence of 13% in the population [2]. Symptoms are pain from the lateral aspect of the elbow on resisted dorsiexion of the hand and on palpation of the affected tissue. Peak prevalence is between 35 and 45 years of age [2], and the cause is primarily repetitive overuse of the extensor muscles of the hand and ngers. Heavy manual labor increases the risk of being affected [2]. The condition is a common example of soft tissue pain from tendons and tendinous muscle insertions. It was formerly looked upon as a straightforward tissue pain of nociceptive-inammatory origin; hence, the common name tendinitis. However, recent research, of which a lot has been of Scandinavian origin, has paved the way for better understanding of the pathology and treatment of chronic tendon pain, e.g. Achilles tendinosis [35]. We now know that in the chronic stage of the disorder the tissue no longer contains acute inammatory reactions [6]. Accordingly, the nomenclature was changed to tendinosis. Tendinopathy is proposed as a collective term for acute and chronic tendon pain. The short-term effect of steroid injections and the paradoxical negative long-term outcome of steroid injections have recently been proven [7]. New treatments focusing on graded eccentric exercise are now well documented to be effective, and such treatments are well known and available to most patients, at least in the Nordic countries, thanks to clinical research by Scandinavian research groups [8,9]. Garnevall et al. take this work to another level by assessing not only physical but also psychosocial aspects of patients suffering with epicondylalgia. They compared these with those of healthy control subjects. Classications of tendon pain such as epicondylalgia are still mostly bio-medically oriented. The Nirschl classication of patients with epicondylalgia into sub-groups according to the degree of pain perceived, assumes correlation of pain severity with the degree of harmfulness. We now know that this is an old

fashioned and faulty perception, and we know that chronic pain is a bio-psycho-social disorder where the pain itself need not stand for something severe or harmful, but that the secondary effects of experiencing pain may be severe and harmful. We have come to recognize that pain is an ailment that involves not only the body but also the mind. This is an evolution from the concept stemming from Descartes, where the brain was conceived as only working as an instrument registering pain, to a tissue capable of an interior process of its own. This does not contradict processes in the peripheral tissue as an origin of pain, affecting the input to sensory systems, but merely that the interpretation and processing of pain is an individual process with aws and merits of its own, leading to the suffering of a pain condition. In other words, the evolution from Descartes has made us realize that body and mind are not conceptually separated entities, but inseparably intertwined and mutually affecting each other.Thus, we need classications of pain conditions that are similarly upgraded and updated. Garnevall et al. found in their study of 54 patients with epicondylalgia and 43 control subjects, that the rebro Musculoskeletal Pain Screening Questionnaire (MPSQ) had better correlation to, and was a better measure for discriminating between the subgroups of the Nirschl classication than pressure pain and isometric loading. This is an interesting nding that yet again raises the issue of what we are actually measuring. The Garneval study is also the rst to examine personality traits by the Swedish University Scales of Personality in subjects with epicondylagia. They found correlation between somatic anxiety and the Nirschl subgroups, as well as with the MPSQ score. This is indeed an interesting an original nding that reminds us that even a simple, well-dened and regionally localized pain condition such as epicondylalgia is a bio-psycho-social disorder and that these issues need to be taken into account for a meaningful classication and subgrouping of patients. Management of these patients may very well gain from a tailored intervention where the psycho-social measures are taken into account. References

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2013.05.001. Corresponding author. Tel.: +46 70 2882768. E-mail address: Magnus.Peterson@pubcare.uu.se (M. Peterson).

[1] Garnevall B, Rabey M, Edman G. Psychosocial and personality factors and physical measures in lateral epicondylalgia reveal two groups of tennis elbow patients, requiring different management. Scand J Pain 2013;4:15562.

1877-8860/$ see front matter 2013 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.sjpain.2013.05.002


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